Payment integrity
Reasoning trace
Centene · payment integrity
Reasoning
How this claim reached its determination
Drug and biologic unit review v1.2, signed off 2026-02-20 — 13 nodes, 12 of them resolved without a model, 18 citations. Read top to bottom: eligibility before policy, policy before pricing, and the finding drafted only once everything above it has answered.
DRX-1
Rule
on match
Active on the date of service
Coverage ran 2026-01-01 to 2026-12-31; the service on 19 Mar 2026 falls inside it. Re-verified at audit with no retroactive change.
Read
$.eligibility.coverage_from$.eligibility.coverage_to$.service_date
DRX-2
Rule
on match
Covered under the plan
Physician-administered drug on the medical benefit — covered subject to prior authorization. Wellcare Medicare Advantage HMO · Louisiana.
Read
$.eligibility.benefit$.eligibility.plan
DRX-3
Rule
on match
Primacy confirmed
This plan is primary. Other coverage: None on file.
Read
$.eligibility.primacy$.eligibility.other_coverage
DRX-4
Rule
on no match
Authorization does not cover the claim as billed
PA-2026-219044 valid 2026-03-01 to 2026-05-31. Authorised: Nivolumab 200 mg per cycle, every two weeks, six cycles. Billed: 240 units on 19 Mar 2026 — 240 mg, 40 mg above the authorised dose.
Read
$.prior_auth.status$.prior_auth.required
DRX-5
Rule
on match
Resolved to v2.0
CPP-061 v2.0, effective 2026-03-01, was in force on 19 Mar 2026.
Read
$.policy_refs$.service_date
pass
[7]
CPP-061 v2.0
DRX-6
Lookup
on match
Codes valid on the date of service
J9299 against C34.90. Every code was billable on 19 Mar 2026.
Read
$.lines
pass
[8]
ICD-10-CM FY2026
[9]
HCPCS / CPT 2026
DRX-7
Lookup
on match
Per-unit rate matches the ASP file
J9299 is $33.62 per 1 mg in the file effective 2026-04-01 to 2026-06-30. 240 units billed = $8,069.76.
Read
$.lines
DRX-8
Rule
on match
Inside the unit ceiling — which is not validation
240 of J9299 against a published ceiling of 480. Derived from the maximum labelled dose over body surface area. The ceiling is a maximum, not an allowance: passing it validates nothing on its own.
Read
$.lines
DRX-9
Needs a scoped call
on field missing
Requires the medication administration record
The medication administration record for 19 March documents 200 mg administered. J9299 bills in 1 mg units, so 200 mg is 200 units. The 40 units above that are recoverable at the 2026 Q2 ASP rate of $33.624 per unit. The agent is sent the claim, not the administration record, so the rules cannot resolve this on the data available.
On the platform this node is a scoped model call over the retrieved record.
Not in the claim
$.record.medication_administration.administered_dose
The branch taken is on field missing, which is a
different outcome from the check evaluating to false.
DRX-10
Rule
on no match
Billed beyond the authorised dose
Authorised: Nivolumab 200 mg per cycle, every two weeks, six cycles. Billed: 240 units on 19 Mar 2026 — 240 mg, 40 mg above the authorised dose.
Read
$.prior_auth.authorized$.lines
DRX-11
Formula
on no match
$1,344.96 recoverable
40 units above the supported dose at $33.624 per unit = $1,344.96.
fail
DRX-12
Retrieval
on match
2 passages retrieved
Scoped to CPP-061 v2.0, the version in force on 19 Mar 2026. Best match on page 1.
On the platform this node is a scoped model call against the indexed policy.
Read
$.lines$.findings
DRX-13
Drafted
on no match
Finding and letter drafted for a reviewer
Separated into 3 layers — coding defect, clinical-evidence defect, payment consequence — with the policy citation and dispute rights already in the letter. Neither is sent by the agent.
On the platform this node is a scoped model call that writes the finding and the letter.
Terminal disposition
Route to a human — pend
ROUTE_TO_HUMAN_PEND
1 check could not be evaluated: the field it reads is not on the claim. 2 other checks did not pass, but the agent does not recommend on the merits while a material check is unresolved. $1,344.96 is at stake. The agent recommends holding for the missing information; a person decides.
The agent recommends holding for missing information. A check could not be evaluated, so no recommendation on the merits is offered.
13 nodes
12 deterministic
0 model calls
18 citations
95% of paths resolved